Aetna U.s. Healthcare Misleads, Suit Alleges

November 11, 1998|By From Staff Reports

A Long Island couple, backed by a new patients' rights organization, sued Aetna U.S. Healthcare on Tuesday, alleging that the company is misleading consumers about the care it approves and financial incentives for doctors.

Irwin and Mara Maltz of North Bellmore, N.Y., backed by the Blackwell Center for Patient Rights, sued after seeing a TV commercial showing how Aetna flew a victim of Crohn's disease to the Cleveland Clinic for treatment.

According to the lawsuit in New York Supreme Court Aetna told the family that treatment at the same clinic was not available for their son, who also suffers from the chronic intestinal inflammation.

The allegation, said Aetna spokeswoman Joyce Oberdorf, is ``ludicrous'' because the commercial portrayed a program designed to provide state-of-the-art care for people when it is not available locally.

``Our New York network has some of the premiere medical centers in the country in it, and we find it difficult to believe that this care would not be available in New York,'' Oberdorf said,

The Maltzes, she noted, previously sued Aetna unsuccessfully over capitation, a system in which doctors are paid set fees per member per month to provide care. ``We wonder if they may be professional filers of suits,'' Oberdorf said.

The new lawsuit says Aetna's booklet ``HMO Plan Benefits'' misleads people about capitation by saying it is intended to ensure high- quality care. The system, the lawsuit alleges, ``can be and often is detrimental to patient care and patient satisfaction.''

In addition, the lawsuit says Aetna refused to pay for a drug for the Maltzes' son that an Aetna-approved specialist said was medically necessary. Aetna said it cannot comment on specifics without a privacy waiver from the family, but noted that it has a process for appeals.